Archived Policies - OBGYN


Assisted Reproductive Technologies

Number:OB402.023

Effective Date:07-01-1999

End Date:12-31-2006

Coverage:

The diagnosis and treatment of infertility may be eligible for coverage and may include, but is not limited to:

  • Evaluation and basic workup includes:
    1. Fertility history and physical examination,
    2. Routine semen analysis, including and limited to count, motility, volume and morphology,
    3. Documentation of ovulation (basal body temperature, serum progesterone, or endometrial biopsy),
    4. Postcoital test (sperm-cervical mucus interaction),
    5. Evaluation of tubal patency (hysterosalpingography),
    6. Urologic consultation for disorders such as hypospadias, Cryptorchidism, varicocele, or genitourinary system infection,
    7. Diagnostic/surgical laparoscopy for diagnosis or treatment of endometriosis,
  • Therapeutic drugs including self injectables such as: hormones, danazol, parlodel, clomiphene citrate, pergonal, metrodin, and etc. (check all appropriate contract provisions.)
  • Artificial insemination (AI)
  • Assistive reproductive technology (a.r.t.) procedures which include:
    1. In vitro fertilization (IVF)
    2. Uterine embryo lavage
    3. Gamete intrafallopian tube transfer (GIFT), sperm
    4. Intracytoplasmic injection (ICSI)
    5. Low tubal ovum transfer
    6. Embryo transfer (ET)
    7. Zygote intrafallopian tube transfer (ZIFT)

Services that are not eligible for coverage include:

  • Reversal of voluntary sterilization
  • Payment for medical services or supplies rendered to a surrogate for purposes of child birth
  • When the contract is silent on the cost associated with cryopreservation and storage of sperm, eggs, and embryos, then it is assumed that benefits are not available. (Subsequent services utilizing such cryopreserved and stored materials are eligible for benefit if they otherwise would have been without cryopreservation)
  • When the contract is silent on the cost associated with the procurement of sperm, or harvesting of eggs and embryos from a donor then it is assumed that benefits are not available
  • Experimental treatments
  • Travel costs

The following immunologic therapeutic approaches have been used to avoid recurrent spontaneous abortion but to date have not been documented to be effective and should continue to be considered investigational:

  • Immunotherapy utilizing paternal leukocytes,
  • Immunotherapy utilizing seminal plasma,
  • Immunotherapy utilizing trophoblastic membranes, and/or
  • Therapy utilizing Intravenous Immune Globulin (IVIG).

Description:

ASSISTED REPRODUCTIVE TECHNOLOGIES (ART) refer to an array of interventions designed to establish a viable pregnancy for those couples who have been diagnosed with infertility. Infertility is defined as the inability to achieve pregnancy after one year of unprotected sexual intercourse despite purposeful attempts at impregnation or the inability to sustain a successful pregnancy. The inability to sustain a successful pregnancy after the loss of three or more consecutive pregnancies, is sometimes referred to as Recurrent Spontaneous Abortion or RSA.

Rationale:

None

Contract:

Each benefit plan, summary plan description or contract defines which services are covered, which services are excluded, and which services are subject to dollar caps or other limitations, conditions or exclusions. Members and their providers have the responsibility for consulting the member's benefit plan, summary plan description or contract to determine if there are any exclusions or other benefit limitations applicable to this service or supply. If there is a discrepancy between a Medical Policy and a member's benefit plan, summary plan description or contract, the benefit plan, summary plan description or contract will govern.

Coding:

None


Medicare Coverage:

None

References:

ACOG, Technical Bulletin, Number 125-February 1989, Infertility.

ACOG, Technical Bulletin, Number 140-March 1990, New Reproductive Technologies.

ACOG, Technical Bulletin, Number 142-June 1990, Male Infertility.

ACOG Technical Bulletin, Number 212 - September 1995, Early Pregnancy Loss.

TEC Assessment Program, Volume 10, No. 18, September 1995, Paternal or Fetal Antigen Immunotherapy for Recurrent Fetal Loss.

West's Smith-Hurd Illinois Compiled Statutes Annotated, Chapter 215, Insurance Act 5, Illinois Insurance Code, Article XX, Accident and Health Insurance, Copr. West Group 1998, Infertility Coverage.

Texas Insurance Code, Article 3:51-6, 3A, In Vitro Fertilization.

Policy History:

Archived Document(s):

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